Sarah E. Roth

Background: Our study examined health care utilization outcomes among individuals participating in Pathways, a community hub model that employs a community-based workforce to deliver care coordination services, in Southwest Washington. Methods: Using community health record and Medicaid claims data between August 2018 and August 2022, we defined our treatment group as Medicaid beneficiaries enrolled in Pathways (N = 395), and our control group as Medicaid beneficiaries referred to any care coordination program (N = 198). We employed difference-in-differences analyses to compare the change over time in the proportion of individuals using care and the amount of health care used per member per year (PMPY). Results: Relative to the control group, the treatment group experienced a significant increase in connection to outpatient care, with a higher proportion accessing primary (9.6%, P = .073), specialty (12.8%, P = .033), and outpatient mental health (11.8%, P = .031) care after enrollment in Pathways. We also observed encouraging trends in acute care use. Conclusions: Participation in Pathways was associated with connection to outpatient health care and promising decreases in acute care use among Pathways participants. Our findings support the evidence base for Pathways as an effective model of care coordination for people with complex health and social needs.

Background Population-based genetic screening and testing programmes have substantial potential to improve cancer-related outcomes through early detection and cancer prevention. Yet, genetic testing for cancer risk remains largely underused. This study aimed to describe barriers and facilitators to patient engagement at each stage of a California-based genetic screening programme, from completing the electronic screener to receiving the test and to identify potential improvements that could support precision medicine-based approaches to patient care. Methods We conducted 26 semistructured interviews among programme participants who did not complete the screener (n=9), those who did not receive the recommended test (n=7) and those who received a genetic test (n=10). Interviewees were selected from patients who recently received a mammogram through one of the participating Southern California clinics. Interviews were transcribed and coded using Atlas.ti. The study used a qualitative descriptive approach to identify similar and contrasting themes among the participant groups. Results This study found that barriers and facilitators to engagement were largely the same regardless of how far participants had moved through the process towards getting a genetic test. We identified four overarching themes: participants wanted clear communication of personal benefits at each stage; participants needed additional information and knowledge to navigate genetic screening and testing; a trusted provider could be instrumental in participants following a recommendation; and repetition and timing strongly impacted participants’ likelihood to engage. Conclusions Providing education about the benefits of genetic screening and testing to patients and their families, as well as clear communication about what each step entails may help patients engage with similar programmes. Strategies aimed at increasing coordination among a patient’s healthcare team can also help ensure information reaches patients in multiple ways, from multiple providers, to increase the likelihood that recommendations for testing come from trusted sources, which supports the uptake of genetic testing.

Three organizations in Clark County, WA, partnered together to implement a pilot program to expand access to personal caregiving services in the homeless crisis response system. The aim of this study is to describe staff and clients’ experiences of the program and its impact on clients’ daily living activities, health and wellbeing, and housing stability. Using a qualitative descriptive design, semi-structured, in-depth interviews were conducted with 12 clients and 5 pilot staff, representing 4 housing service providers. Interviews were analyzed descriptively to examine staff and clients’ perspectives and experiences with the personal care services pilot program. Caregivers helped clients establish routines, find companionship, and connect to health and social services both logistically and socioemotionally, supporting clients’ stabilization and reducing barriers to healthcare. Hiring and retaining caregivers remained difficult due to the challenging nature of the work. Staff interviews highlight the need for additional supports to better retain caregivers. Findings from the evaluation have important implications for addressing the needs of individuals exiting homelessness and suggest that personal caregivers can play an important role in supporting the stabilization process. However, employing strategies such as training and increasing wages and benefits that support the needs of the caregiving workforce is essential to sustain this type of service delivery model.

This study aimed to describe participants' experiences of Pathways, a community hub care coordination model, including its impact on their lives and their relationship with the Pathways community health worker (CHW). The research team conducted semistructured, in-depth interviews with Pathways participants (n = 13) and analyzed interviews using thematic analysis. Interviews reveal how Pathways helps individuals navigate systems more confidently, increases access to needed resources, and improves well-being. CHWs defined participants' experience, providing a safe, reliable setting to make progress toward goals. Our findings support the evidence base for Pathways as an effective model of care coordination for people with complex needs.

Background The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact. Objective We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services. Design The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups. Participants Our study population consisted of 1220 people (740 treatment, 480 control), aged 18–65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020. Interventions The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention. Main Measures Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization. Key Results Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, ppp<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed. Conclusions DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Community-based public health interventions often rely on representative, spatially referenced outcome data to draw conclusions about a finite population. To estimate finite-population parameters, we are posed with two challenges: to correctly account for spatial association among the sampled and nonsampled participants and to correctly model missingness in key covariates, which may be also spatially associated. To accomplish this, we take inspiration from the preferential sampling literature and develop a general Bayesian framework that can specifically account for preferential non-response. This framework is first applied to three missing data scenarios in a simulation study. It is then used to account for missing data patterns seen in reported annual household income in a corner-store intervention project. Through this, we are able to construct finite-population estimates of the percent of income spent on fruits and vegetables. Such a framework provides a flexible way to account for spatial association and complex missing data structures in finite populations.

Understanding health outcomes and patterns of health care utilization associated with patients' cumulative social determinant of health (SDOH) risk is essential to supporting better health care. This study compared mental and physical health outcomes and health care utilization by increasing number of social needs among a clinical adult population. Surveys were sent to 6000 patients with recent visits to 7 primary care clinics in Portland, Oregon in 2018. The final study sample included respondents who matched to medical claims data, N = 1748. The authors used a modified logistic regression model to estimate risk ratios for the relationship between cumulative SDOH factors and self-reported chronic conditions, and a 2-part model to estimate the effects of cumulative SDOH risk on health care utilization. Increased SDOH need was associated with increasing likelihood of worse self-reported health outcomes, especially mental health. Compared with those with no SDOH need, having 1–2 SDOH need(s) (adjusted risk ratio [aRR] 1.25; 95% confidence interval [CI]: 1.06–1.46) and 3 or more SDOH needs (aRR 1.45; 95% CI: 1.22–1.73) had a greater risk of reporting any behavioral health condition. However, the number of SDOH had a graded but inverse impact on use of mental health care services where fewer visits were observed among those using care. Having SDOH was associated with increased likelihood of having an emergency department visit and increased number of primary care visits. This study demonstrates the compounding impact of SDOH on health and health care use. This highlights the importance of collecting SDOH, including the total number of SDOH needs, when considering a patient's health and health care.

Ensuring access to high-quality outpatient care is an important strategy to improve COVID-19 outcomes, reduce social inequities, and prevent potentially expensive complications of disease. This study assesses the equity of health care response to COVID-19 by examining outpatient care utilization by factors at the individual and community levels in the 12 months prior to and following COVID-19 diagnosis. Employing a retrospective, observational cohort design, we analyzed electronic health record data from a sample of 11,326 adults diagnosed with COVID-19 between March and July 2020. We used two-part models to estimate changes in use of primary and specialty care by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our findings showed that while overall probability and counts of primary and specialty care visits increased following a positive COVID-19 diagnosis, disparities in care utilization by race/ethnicity and living in a socially vulnerable community persisted in the year that followed. These findings reiterate the need for strategic approaches to improve access to and utilization of care among those diagnosed with COVID-19, especially for individuals who are traditionally undeserved by the health system. Our findings also highlight the importance of systematic approaches for addressing social inequity in health care.

Using an embedded mixed-methods approach, this study assesses efforts to improve nutritional quality of inventory at food banks. All else equal, food banks with medium and high levels of nutrition-focused food banking strategy adoption had lower mean percentages of unhealthy inventory compared to those with none. Despite positive progress in the charitable food system as a whole, national key stakeholders identified several challenges, including cost and donor reliance, in continuing this work. Findings highlight the significant progress of food banks to adopt nutrition-focused strategies and distribute healthier foods and underscore the role these strategies may have in shaping inventory quality.